Effectiveness and Safety of Enhanced Postoperative Care Units for Noncardiac, Non-Neurological Surgery: A Systematic Review

High rates of postoperative deterioration among certain patient groups on general surgical wards have driven interest in high-acuity postoperative care facilities, which provide an intermediate level of care between standard surgical wards and intensive care units (ICUs). These facilities, nominally termed enhanced postoperative care units (EPCUs), provide many key critical care elements outside the ICU, including increased nurse-to-patient ratios, specialized medical personnel, and critical care interventions, such as vasopressor therapy. While the current organization and terminology of these units vary widely, emerging evidence suggests they may have a clinical impact, especially within anesthesia-led models, though research remains limited. This review aimed to assess existing literature on the effectiveness and safety of EPCUs on patient and health service outcomes in adults after noncardiac, non-neurological surgery. The Cochrane Library, MEDLINE, Embase, and Scopus were searched from 2010 to April 2025. Inclusion criteria included adult patients undergoing any noncardiac, non-neurological surgery admitted to an EPCU. Experimental, quasi-experimental and observational study designs were eligible. Two reviewers assessed titles, abstracts and full-text papers against inclusion criteria, evaluated the risk of bias using JBI standardized instruments, and applied the GRADE approach to assess the certainty of evidence. Due to clinical and methodological heterogeneity, a meta-analysis was not possible, and a narrative synthesis is provided. From 9774 records, 13 reports from 12 studies met the inclusion criteria. The narrative synthesis showed that while some studies observed positive effects in favor of the intervention, the overall findings were mixed. Two studies reported a statistically significant decrease in 30-day mortality in favor of EPCUs compared to usual care. One study reported a statistically significant increase in days at home at 30 days for patients admitted to an EPCU. Three studies found that EPCU admission had a statistically significant positive effect on hospital length of stay. The included studies had low to moderate risk of bias, with small sample sizes and an overall very low certainty of evidence. Current evidence is insufficient to definitively establish the effectiveness and safety of EPCUs after noncardiac, non-neurological surgery. Only a small number of studies were identified, with considerable clinical and methodological heterogeneity among the studies. Although the current research is not yet comprehensive, the initial findings suggest potential benefits of EPCUs in this patient population that warrant further consideration and exploration. Additional high-quality research is needed, and any expansion of EPCUs should proceed cautiously with thorough evaluation to ensure effectiveness and safety.